Anticoagulation in an Older Adult With Falls and Prior GI Bleed
An 82-year-old woman with permanent atrial fibrillation, hypertension, type 2 diabetes, and a prior transient ischemic attack presents for medication review. Her eGFR is 28 mL/min/1.73 m2, weight 58 kg, and serum creatinine 1.6 mg/dL. Eight months ago she had a duodenal ulcer bleed while taking warfarin; Helicobacter pylori was eradicated and she now takes omeprazole. She has fallen three times in six months, once fracturing a wrist, and lives alone; her daughter checks in twice weekly. Current medications are aspirin 81 mg daily, metoprolol, amlodipine, atorvastatin, and omeprazole. Blood pressure is 148/82 mmHg and her pulse is irregular at 92/min. She is independent in activities of daily living but forgets doses and sometimes doubles them. She asks whether she can stop the aspirin because it causes bruising.
1. Which anticoagulant and dose would you recommend, and how would you handle her aspirin? Explain the competing risks and what you would tell her.
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Her stroke risk is high: age 82 gives 2 points, female sex 1, hypertension 1, diabetes 1, and prior TIA 2, for a CHA2DS2-VASc score of 7. Her bleeding risk is also high: prior GI bleed, age over 65, hypertension, renal impairment, and antiplatelet use. The decision is not whether she has risk factors but how to reduce net harm.
Apixaban is a reasonable choice because it has less major bleeding than warfarin in older patients and is usable at this eGFR. She meets all three dose-reduction criteria: age at least 80, weight 60 kg or less, and creatinine at least 1.5 mg/dL. The reduced dose is 2.5 mg twice daily. Avoid dabigatran at this eGFR and avoid rivaroxaban unless there is a compelling reason.
Stop aspirin. It is being used without a clear vascular indication and adds bleeding risk without proven benefit in atrial fibrillation alone. Continue omeprazole, control blood pressure, and address falls. Explain that anticoagulation lowers stroke risk but does not eliminate it and increases bleeding risk; document a shared decision and a plan to reassess.
2. List the modifiable bleeding-risk and adherence issues you would address before she leaves clinic, and explain how you would monitor her.
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Modifiable issues include uncontrolled hypertension, falls, duplicate antiplatelet therapy, and inconsistent dosing. Check orthostatic blood pressure, review sedating medications, assess gait and home hazards, and involve physiotherapy. Continue a proton pump inhibitor because of the prior ulcer bleed. Ask about alcohol and over-the-counter NSAIDs.
Adherence is a major safety issue because doubled doses increase bleeding. Use a pill organizer, simplify the regimen, and involve her daughter with permission. Ask her to repeat back the plan. Check renal function and hemoglobin at baseline and every 3 to 6 months, and sooner if she becomes dehydrated or has a bleeding episode. Reassess falls and blood pressure at each visit. If she declines anticoagulation after discussion, document the discussion and follow up rather than simply omitting therapy.